Provider Demographics
NPI:1265773220
Name:FRISCH, GLEN DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:DOUGLAS
Last Name:FRISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 MAKALOA ST
Mailing Address - Street 2:STE 204-202
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3232
Mailing Address - Country:US
Mailing Address - Phone:808-979-7047
Mailing Address - Fax:
Practice Address - Street 1:1580 MAKALOA ST
Practice Address - Street 2:STE 660
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3237
Practice Address - Country:US
Practice Address - Phone:808-979-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD - 120822084P0800X
MOR1H802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE80061Medicare UPIN